LIBRARY OF CONGRESS. 



£ hct/l , 



PRESENTED BY 



UNITED STATES OP AMEEIOA. 



A HISTORY 



OF THE 



DIAGNOSIS, PATHOLOGY AND TREATMENT 



YELLOW FEVER. 



V^o 



BY 



J. B. MARVIN, M. D. 



Late Resident Physician to the Yellow Fever Hospital; Professor of Chemis- 
try and Microscopy, Hospital Medical College; President of 
the Louisville Microscopical Society, Etc. 



Q 




Reprinted from the American Practitioner, November, 1878. 



LOUISVILLE, KY 
1878. 









>> 







fc 






YELLOW FEVER. 



When yellow fever first began its ravages in the south, 
Louisville declared against quarantines, opened wide her 
doors, and bade the fleeing refugees from the plague-smitten 
districts to come and freely partake of her hospitality. It 
soon became evident that among the many refugees who 
came to our city that cases of yellow fever would occur ; and 
the mayor and board of health speedily set about preparing a 
suitable hospital for the reception and treatment of such cases. 

The hospital. — One of the buildings of St. John's Hospital, 
beautifully situated on a hill three miles south of the city, and 
but a short distance from the junction of the Cincinnati and 
Nashville railroads, was selected. Two pavilion hospitals, 
containing respectively eight and ten rooms, were also erected 
and thoroughly equipped, a corps of experienced nurses en- 
gaged, and the writer appointed resident physician. These 
buildings were admirably adapted for the required purposes. 
The rooms were large and well ventilated ; the partitions did 
not extend to the roof; all the rooms communicated with 
each other, and opened on a wide hall-way. 

Number of patients. — The first patient was admitted on Au- 
gust 5th; the last on October 17th. Total number admitted, 
eighty-nine; of which number seventy had genuine yellow 
fever — sixty-six being among southern refugees, and four 
originating in Louisville, among the inhabitants of the so- 
called " infected district," near the Louisville and Nashville 
railroad depot; fourteen had intermittent fever, and five were 



4 Yellow Fever. 

not sick, children whose parents were sick in the hospital. 
The recoveries number fifty-eight ; deaths thirty-one, from 
yellow fever. When we take into consideration the fact that 
all of these patients were moved to the hospital after the dis- 
ease had become well marked, — some developing the disease 
while en route to this city, others being moved from Paris, 
Tenn., a distance of two hundred and fifty miles, and other 
southern towns, after being sick for several days, — the above 
mortality is not large. 

Symptoms. — None of the cases were seen in the incubating 
stage of the disease. Most of the cases were in the second 
stage, some in the third stage; black vomit, etc., having oc- 
curred. The symptoms on admission were generally a hot, 
dry and harsh skin ; in some cases that had been moved a 
long distance the skin was cold, clammy and bathed in pro- 
fuse perspiration. Eyes bright and glistening; conjunctiva 
badly injected; the sclerotic tinged yellow, except in cases of 
several- days' standing, when the eyes were heavy and luster- 
less, face flushed, great pain in small of the back, legs and 
head; tongue red and coated; bowels costive; great irregular- 
ity in pulse and temperature — the pulse running from thirty- 
five to one hundred and forty beats per minute, temperature 
ranging from ninety-seven to one hundred and six degrees. 
There is no correspondence between the pulse and tempera- 
ture; frequently a high temperature being associated with a 
slow pulse, and vice versa. The respirations are quick and 
shallow. The perspiration is generally strongly acid in reac- 
tion, and possesses a most peculiar odor, difficult to describe, 
but once recognized never forgotten — a dysenteric, rotten-hay 
or slacking-lime smell, not cadaveric as generally described by 
writers. 

When the disease is well established, the fauces are swollen 
and of an intense red color; the tongue is enlarged, very red, 
the papillae being very prominent, the edges are indented. 
At first there is a thick white or creamy coating on the sur- 
face; frequently the tip, edges and narrow space on each side 
of the median line are clean and not coated. As the disease 



Yellow Fever. 5 

< 

progresses the coating gradually disappears ; and in severe 
cases the papillae become obliterated, its surface becomes 
smooth and cracked, very red and dry,, resembling a piece 
of raw beef. The tongue bears no resemblance to the pale, 
flabby and enlarged tongue of malarial fever. 

The skin is generally moist, and becomes tinged yellow in 
varying intensity. In some cases there is a herpetic eruption 
on the body and around the mouth and nose; severe urticaria 
occasionally occurs. Sudamina are frequent. A considera- 
ble proportion of convalescents suffer with furuncles and shed- 
ding of the epidermis. 

The bowels become loose, the stools being very offensive, 
and generally black and tarry in appearance. Occasionally 
the stools resemble pea-soup, or they may be composed of 
shreddy mucus mixed with blood or bile, or be composed of 
blood and resemble black vomit. 

The urine is high-colored, varying from amber to a greenish 
coffee color. This high color is due to an admixture of blood 
or bile, or frequently simply to a large excess of the normal 
pigment. The odor may be normal, faint and sweetish ; in 
some cases it is very disagreeable, something like carburetted 
hydrogen or decayed leaves. The quantity is generally dimin- 
ished ; the reaction is acid, very seldom neutral, and never 
more than feebly alkaline, no matter how much blood or bile 
there may be in it. The specific gravity varies from 1.004 to 
1.030; the average being 1.020. It is high in the beginning 
of the attack; diminishes as the disease progresses; rising 
again as convalescence ensues. A lowering in the specific 
gravity, with an increased quantity, of urine, is a favorable 
symptom. Sugar is never present, unless the patient has had 
previous diabetes mellitus. Bile, in varying amount, is pres- 
ent sooner or later in the great majority of cases. Albumen 
is present in every case, — the amount varying from a trace to 
nine-tenths the total amount of urine passed. The greater 
the amount of albumen, the graver the prognosis. In severe 
cases, albumen always appeared as soon as the second day; 
in mild cases, it may not appear until the fourth or fifth day. 



6 Yellow Fever. 

» 

Albumen generally disappears from the urine as convalescence 
sets in ; but it may persist until the patient is up and able to 
walk about. 

Associated with albumen are granular tube-casts, stained 
greenish brown or yellow with bile, renal epithelium, more or 
less disintegrated, and large quantities of fine granular debris. 
The amount of this granular debris is much greater than I 
have ever seen in cases of acute Bright's disease from other 
causes. Renal derivations generally appear on the second 
day in severe cases ; in mild cases, they may not be found 
until the fourth or fifth day. Vesical epithelium, in varying 
amount, is generally present in the urine. In some few cases 
there was a marked shedding of vesical epithelium preceding 
the appearance of renal derivations. No symptoms are of 
more value in the prognosis of a case than the amount of 
albumen and renal derivations. The smaller the quantity of 
albumen and tube-casts, the milder the attack, and vice versa. 
Renal derivations usually disappear as convalescence sets in, 
but they may persist in severe cases until the patient is able 
to be out of bed. In a small proportion of cases there were 
vesical and renal hemorrhages in considerable quantities. 
Urea varies from normal to less than one-half the normal 
amount; most generally it falls below normal. The urine 
speedily undergoes decomposition ; in fact decomposition may 
take place in the bladder. Large quantities of vibrios and 
bacteria may be present when the urine is voided. 

The breath. — Pure glycerin was smeared in the center of a 
clean, new glass slide, and held an inch or two from the nos- 
trils or mouth of the patient. After a few minutes' exposure 
.to the breath, the slide was examined under the microscope. 
Large quantities of very active vibrios were revealed, also 
roundish oval bodies, bacteria. 

The blood. — A drop of blood from the finger was received 
on a slide, covered, avoiding pressure, and examined. The 
corpuscles were jagged and crenated ; frequently the red glob- 
ules were breaking up, forming as it were daughter-cells. In 
severe cases, especially after black vomit had occurred, there 



Yellow Fever. 7 

was a very large increase in the number of white corpuscles, 
the proportion frequently being as one white to five or ten 
red corpuscles. Scattered among the corpuscles were found 
vibrios and bacteria, frequently five or six very active bacteria 
being in the field. More extended observations, in this and 
other fevers, must be made before attaching undue import- 
ance to the existence of these bodies in the blood and breath. 
Every possible precaution was taken, in making these exam- 
inations, to avoid contaminations. The examinations were 
made with a Tolles -^ inch immersion objective and a "B" 
ocular. 

The stomach. — Irritable stomach and nausea, in varying in- 
tensity, are present in all cases. After the stomach had been 
emptied of food, the first ejections consist of glairy mucus 
and epithelium, streaked with blood, bearing a striking resem- 
blance to the rusty sputum of pneumonia. Bilious matter 
was very frequently ejected, sometimes in considerable quan- 
tity. Pure blood was frequently ejected in large quantities ; 
later in the disease, vomiting of blood frequently alternating 
with and following black vomit. The vomit is acid, patients 
frequently complaining of its burning the throat and mouth. 

Black vomit occurred in about fifty per cent, of the cases, 
the amount varying from a few spoonfuls to more than a pint 
at each ejection. This symptom has not proved as unfavora- 
ble as is generally believed. Ten cases have recovered after 
having had black vomit. One case, a mulatto, having vom- 
ited a large quantity of it on three different occasions, with 
intervals of one and two days, yet recovered. The coffee- 
ground or black vomit consists of blood, more or less broken 
down and digested by the gastric juices and bile, epithelium 
and fat globules. JThere were also found large quantities of 
vibrios, an oval (not recognized) fungus, and frequently very 
large crystals of hematoidin. 

Hiccough and retching are constant symptoms, and may 
prove very distressing. In some severe cases there are spas- 
modic contractions of the diaphragm, causing most violent 
and painful retching; the contraction is so violent in some 



8 Yellow Fever. 

cases as to partially raise the patient from the pillow. Gener- 
ally the epigastrium is not markedly sensitive on pressure. 
In those cases having a temperature ranging over one hun- 
dred degrees, great restlessness and nervousness are present; 
in those cases in which the temperature ranges from ninety- 
seven to one hundred degrees, the patient lies in a stupid, 
lethargic condition. A hemorrhagic tendency is present in 
all cases. In all severe cases, hemorrhage varying in amount 
occurs from some portion of the body — the eyes, nose, ears, 
mouth, rectum, uterus, bladder, kidneys, etc. ; most frequently 
from the mouth and nose. The hemorrhage is passive, gener- 
ally an oozing, and is easily controlled ; in some cases, how- 
ever, it comes in a stream from the nose. These passive 
hemorrhages are caused either by an alteration in the blood 
itself, or some change in the epithelium lining the vessels and 
mucous membranes, or by both. 

The unfavorable symptoms are a fiery red, dry and cracked 
tongue; irritable stomach, with constant nausea and vomiting; 
great pain over the bowels ; suppression of urine ; passage of 
feces in bed ; rejection of food and medicine by the stomach 
and bowel; great delirium, getting out of bed, etc. 

Before death muscular twitchings frequently occur, the ex- 
tremities get cold and clammy, and large drops of sweat 
appear on the face and neck. The temperature may fall to 
97 degrees; immediately after death the temperature begins 
to rise, and may go as high as 106^ degrees under the axilla, 
the body remaining warm for twelve hours or more. Spare- 
built persons, with light hair and complexion, resist the dis- 
ease better than stout/ plethoric persons, with dark hair and 
complexion. The average duration of the disease in fatal 
cases is four days. 

Diagnosis. — The diagnosis of yellow fever is not as easily 
made as one would be led to believe from the literature of 
the subject. It presents a striking resemblance, in many re- 
spects, to pernicious intermittent and bilious remittent fevers. 
The chief diagnostic points are the peculiar smell, tongue, 
great irregularity of pulse and temperature, and the constant 
existence of albumen and renal derivatives in the urine. 



Yellow Fever. 9 

Pathological anatomy. — Cadaveric rigidity occurs very early, 
and is very marked. The skin is of a bright yellow or saffron 
color, quickly changing to a purplish black over the depend- 
ent portions of the body. In severe cases the entire surface 
of the body becomes purplish black within six hours. The 
mucous membranes are tinged yellow, and the cellular tissues 
are stained of a bright yellow color. 

The peritoneum and mesentery may be normal ; in a con- 
siderable proportion of cases they are more or less congested. 

The stomach, as a rule, does not appear congested, as stated 
by writers upon this disease. The organ may be greatly dis- 
tended with gas, filled with black vomit, or almost empty; 
more or less black vomit is always present. There is no 
marked injections of the veins — no ecchymotic spots; the 
mucous membrane is pale, there being no hemorrhagic ero- 
sions or ulcerations, no evidences whatever of acute catarrh. 
In only one case was there found thickening of the mucous 
membrane and enlargement of the rugae. On examining a 
thin section under the microscope the glands are normal, the 
villi are not changed ; the free extremities of the villi contain 
blood, which has oozed from the capillaries and is piled up 
under the epithelium. The microscopic examination clearly 
proves that the hemorrhage in this organ is passive, and not 
dependent on active congestion. The clinical history of the 
vomit confirms the microscopic examination. The changes 
stated to have been found in the stomach are post mortem 
changes. 

The intestines generally show no marked changes; they al- 
ways contain more or less black vomit. In some cases there 
are patches which are badly congested. In one case intus- 
susception was found in three different places. A section of 
the gut, when examined under the microscope, may appear 
normal ; in other cases, the villi and glands are in a state of 
acute catarrh. 

The spleen presents no marked deviation from health ; gen- 
erally normal in size and consistency, and frequently darker in 
color. In cases giving a history of previous malarial trouble, 



io Yellow Fever. 

the organ was considerably enlarged. On microscopic exami- 
nation, the organ appears normal, except in those cases hav- 
ing had malarial fever, when the pigmentation peculiar to 
malarial fevers was found. 

The liver varies in color, being bright yellow, orange, nut- 
meg or mottled, or normal. The organ is generally enlarged, 
the enlargement being very slight in some cases. It is very 
firm, tough and elastic. On section, the hepatic cells are 
found in a granular condition, frequently stained with bile; 
nucleus pale and frequently obscured by oil globules. Within 
and around the cells are large quantities of oil globules, there 
being a fatty infiltration as well as fatty degeneration. There 
is frequently an increase in the connective tissue, with a con- 
sequent pressure upon and destruction of the neighboring 
cells. In one case, aged twenty-seven years, not a drinker, 
who had suffered at intervals for two years with malarial fe- 
ver, there was an enormous increase in the connective tissue, 
visible to the eye, giving the organ the appearance found in 
cirrhosis. On section, all the appearances of cirrhosis were 
found; in parts there were fatty degeneration and infiltration, 
and a large amount of a delicate fibrous growth, resembling 
areolar tissue, minus the fat. 

The kidneys are congested, and in some cases considerably 
enlarged ; the capsules do not readily peel off; the malpighian 
tufts are prominent. On section, tubal and intertubal hemor- 
rhages are frequently found. The tubes are choked up with 
fine granular debris and epithelium ; in some parts the tubes 
are empty and denuded of epithelium. Fatty degeneration, 
slight in degree, is frequently found. 

The bladder may present no changes ; it may be full or 
empty and slightly contracted. In those cases having sup- 
pression of urine for any length of time before death, it is 
badly congested, the mucous membrane showing large ecchy- 
motic spots. The gall bladder always contains thick yellow 
or blackish bile ; in some cases it is enormously distended, 
the mucous membrane being congested. 

The lungs and pleura presented no constant changes. In 



Yellow Fever. 1 1 

several cases there were recent pleuritic adhesions ; in one case 
there was severe pneumonia. In some cases the lungs are 
completely collapsed. The color is generally dark and mot- 
tled ; ecchymotic spots are frequent. 

The heart may be full or empty. In some cases there is 
marked fatty degeneration, the walls being pale and friable. 
Frequently the organ is normal. The pericardium always 
contains more or less reddish fluid, the amount varying from 
one to six ounces. No lesions were found in the cerebrum, 
nor constant changes at the base of the brain. In some cases 
which had had marked delirium, congestion and softening 
were found at the base. The spinal cord was not examined. 

Ti'eatment. — On admission the patient is given a hot mus- 
tard foot-bath while under the cover ; he is covered with one 
or two blankets, sufficient to keep up the perspiration ; profuse 
and indiscriminate sweating, by means of blankets or other- 
wise, is injurious. If the bowels are at all costive, half an 
ounce of castor-oil, with fifteen drops of turpentine, are given. 
If the patient objects to oil, or there is much nausea, with foul 
tongue, one grain of calomel and three or four of bicarbonate 
sodium are given every hour until four doses have been taken. 
If there is much nausea or retching, a pint of tepid water, 
containing a dessert-spoonful of mustard and salt, is given to 
empty the stomach. In all cases five grain doses of quinia 
were given every two or three hours until cinchonism was 
produced, a sufficient quantity being given daily to keep up a 
moderate cinchonism. If the stomach was irritable, the qui- 
nia was given in thirty grain doses by enema every six hours. 
In a few, cases, after cinchonism had been induced, ten grain 
doses of salicylate of sodium, every six hours, were substituted 
for quinia, apparently with good effect. 

Whenever the skin became very hot and dry, the patient 
was sponged off with cold water, to which a few ounces of 
alcohol had been added, the sponging being repeated as often 
as necessary. Cracked ice and ice-water, in small quantities 
at a time, were allowed ad libitum. If the tongue became 
very dry, red and cracked, dessert-spoonful doses of turpen- 



12 Yellow Fever. 

tine emulsion — containing twenty per cent, of turpentine — 
were given every three or four hours. If this was rejected, 
fifteen drop doses of dilute muriatic acid, every three or four 
hours, were substituted. A pinch of salt placed on the tongue 
would frequently relieve hiccough ; in severe cases, tincture of 
valerianate of ammonia was better. Lime water, subnitrate of 
bismuth, creasote or chloroform, in small doses, was useful in 
quieting the stomach and relieving nausea. When there were 
present nausea and frequent vomiting, with desire to go to 
stool, with pain in bowels and great tenesmus, the following 
prescription was most valuable : 

R Bismuth, subnitrate, 3 ij 

Creasote, gtts. viij 

Lime water, 3 ij. M. 

Sig. Dessert-spoonful pro re nata. 

If there was much tenderness over the bowels, a blister, six 
by six inches, was applied ; in mild cases, a mustard-plaster or 
turpentine stupe was substituted. In stout, plethoric persons 
six or eight leeches were applied over the bowels ; the leeches 
generally die from the bad blood. If there is any difficulty in 
passing urine, or diminution in its quantity, half an ounce of 
the infusion of digitalis with ten grains of acetate of potash, is 
given every two or three hours. . This proved a most valuable 
remedy, only failing in two cases. In addition, a mustard- 
plaster, cupping, or alternate applications of warm and cold 
water over the bowels, were useful. Hypodermic injections 
of one-eighth of a grain of muriate of pilocarpine were tried 
in several cases, but without apparent benefit. 

For nervousness and sleeplessness, chloral hydrate is the 
best remedy; give thirty grains each of chloral hydrate and 
bromide of potash, in one or two ounces of warm milk, by 
enema. This combination has a most happy sedative effect ; 
it also lowers the temperature. In some cases, tincture of 
hyoscyamus has a happy effect. 

Patients are very sensitive to the effects of opium and its 
salts; very small doses, either by the mouth or rectum, pro- 



Yellow Fever. 13 

during alarming narcosis. Opium did not appear to interfere 
with the proper functions of the kidneys ; its use was discon- 
tinued solely on account of its effect on the brain. A num- 
ber of patients were given morphia while en route to this city ; 
they never came from under the influence of the drug, but 
lay in a stupid, lethargic condition, pupils contracted, and 
died with all the appearances of narcotic poisoning. In some 
patients, who were constant eaters of morphia, most distressing 
appeals were made for it. Various devices were resorted to 
in order to deceive them ; about a fourth of a grain of quinia 
in powder was given, and followed by thirty grains of chloral 
hydrate. If this failed, a hypodermic injection of eight or ten 
minims of water had the desired effect, quieting the cries of 
the patient and putting him to sleep. 

If hemorrhage from the nose or mouth became free, a spray 
of Monsel's solution (half strength), always checked it. For 
hemorrhages from the stomach and bowels, if deemed advisa- 
ble to check them, ten minims of Monsel's solution were given 
every hour. For renal hemorrhage, ten grains of gallic acid 
were given every three hours. In some cases fifteen minim 
doses of aromatic sulphuric acid were substituted. 

Stimulants are required in every case. Port wine proved 
most acceptable and beneficial, it being retained when the 
stomach rejected everything else. Acid wines and cham- 
pagnes disagreed in every case ; complaints of their bad effects 
were so general, that they were discontinued. Brandy and 
whisky were given in all cases, either by mouth or rectum. 
During convalescence, ale and beer were much relished and 
were freely given. During the first two or three days of the 
attack, the less food taken the better. Milk, chicken-broth, 
beef essence, etc. , according to the desire of the patient, were 
given in small quantities every hour. During convalescence, 
oyster soup, soft boiled eggs, crackers, toast, etc., in moderate 
quantity, are given. Great care is required to prevent the pa- 
tient from' over-eating. Not a single relapse occurred in this 
hospital, which is largely attributable to the great caution 
exercised in regulating the dietary of the patient. 



14 Yellow Fever. 

General remarks. — Yellow fever is a continued fever, marked 
by slight remissions. Of the severe form of the disease there 
are two distinct types — one characterized by a hot, dry skin, 
and a temperature ranging from one hundred degrees to one 
hundred and six degrees ; in the other variety the temperature 
may rise to one hundred and two degrees for the first day or 
two ; it then falls and never rises above one hundred degrees, 
generally ranging from ninety-seven to one hundred degrees ; 
the skin is cold and clammy, and is more markedly yellow 
than in the first variety; the pupils are contracted; this latter 
variety is the more fatal. 

The disease is clearly dependent upon a specific blood poi- 
son, as yet not demonstrated by the microscope, unless we 
regard the changes found in the blood as detailed above, as 
the cause rather than a result of the disease. By adopting the 
theory of specific blood poisoning, the symptomatology of the 
disease is readily understood. Every carefully observed and 
recorded fact bearing on the contagiousness or infectiousness 
of the disease is of great importance. As bearing on this 
subject, I wish to record the following experience : 

I remained at the hospital for a month as resident physi- 
cian ; eat and slept on the ground-floor in the building with 
patients, made daily examinations of the various excretions 
and secretions of the patients, and held frequent post mortem 
examinations. I never had the slightest symptom of the dis- 
ease. There were twenty-eight employes on the premises as 
nurses, cooks, washer-men, etc., in constant contact with the 
patients. Physicians and clergymen from the city paid daily 
visits to the hospital. The ladies of the Flower Mission paid 
frequent visits, going through the wards distributing flowers, 
etc. These parties, returning to the city, came in contact 
with numerous persons; yet not a single individual who re- 
mained at the hospital, or who visited it or came in contact 
with parties visiting it, ever had yellow fever or any disease 
resembling it. The clothing and baggage of the patients were 
not burned or disinfected, but were stored in the building in 
which the nurses and myself slept and eat. 



Sulphate of Cinchonidia. 15 

Only such hygienic regulations were adopted as would be 
enforced in any well-regulated hospital. The rooms were well 
ventilated and kept scrupulously clean. The bedding and bed- 
clothes were kept clean, and whenever soiled were aired and 
washed. The mattresses were never burned. Vomit, dejecta, 
etc., were not allowed to remain in the rooms, were emptied 
in pits about a hundred yards from the wards. The vessels, 
bed-pans, etc., were kept clean ; if they smelt at all, they were 
aired or sprinkled with carbolic acid. Dead bodies were not 
allowed to remain in the wards, but were carried to the dead- 
house. 

Whenever the nurses or myself felt "out of sorts," quinia 
was freely given. I had been troubled greatly with malaria 
before going to the hospital, and was taking quinia daily; at 
the hospital I suffered less from malaria than when in the city. 

Louisville, Ky. 



H MW 



